Upper airway surgery should not be first line treatment for obstructive sleep apnoea in adults ( Adam G Elshaug)

Key points
Upper airway surgery for obstructive sleep apnoea in adults is resource intensive with low and inconsistent clinical effectiveness
Continuous positive airway pressure (CPAP) plus conservative weight and alcohol management should be first line treatment
When CPAP treatment fails, mandibular advancement devices may be considered (with conservative management) as second line treatment
Surgery for obstructive sleep apnoea should be done within controlled clinical trials; patients should be informed about the trial, as well as of the inconsistent results of surgery, its potential side effects, and the potential for relapse

The clinical problem
The prevalence of obstructive sleep apnoea in high income countries is estimated to be 20% for mild disease and 6-7% for moderate or severe disease. The condition is associated with multiple morbidities, motor vehicle crashes, and reduced health related quality of life. Clinical guidelines recommend continuous positive airway pressure (CPAP) with weight and alcohol management (if indicated) as first line treatment for symptomatic, moderate to severe obstructive sleep apnoea. Upper airway surgery (such as uvulopalatopharyngoplasty) may also be done, but evidence does not support its use.However, use of surgical procedures is widespread and increasing in Australia and elsewhere (such as the Nordic countries).We propose that upper airway surgery should not be first line treatment for obstructive sleep apnoea in adults.

The evidence for change
An array of surgical procedures is used either concurrently or stepwise over multiple operations. A recent multicentre retrospective audit revealed substantial procedural variability; the observed cohort (n=94) received 41 varying combinations of surgical procedures. In a Cochrane review of seven randomised controlled trials (n=412) in 2005, the results of surgery were inconsistent: significant improvement in polysomnography occurred in only three trials (combined n=225), and health related quality of life improved in only four trials (combined n=138). Comments on the clinical significance of both these measures were limited, and the review concluded that surgery had a lack of an impact on symptoms (except in two trials) and that overall significant benefit was not shown. Even where improvements in quality of life have been shown immediately after surgery, these were rarely sustained beyond 12-24 months.
A recent systematic review of 48 studies (4 randomised controlled trials, 17 prospective studies of various designs, 23 retrospective case series, 4 unspecified design) found that up to 62% of 21 346 patients who had surgery reported persistent adverse effects,6 such as persistent dry throat, globus sensation, difficulty in swallowing (including spontaneous nasal regurgitation), voice changes, and disturbances of smell and taste. Up to 22% regretted having surgery.
An additional meta-analysis evaluated 18 surgical studies (n=385; 17 level four audits, one randomised controlled trial).7 Success, as measured by the number of patients achieving a post-surgery apnoea/hypopnoea index of 5 or less (a clinically significant standard against which CPAP is judged), was limited.8 Pooled success rates were 13% for phase I procedures including uvulopalatopharyngoplasty (14 studies, n=347) and 43% for phase II procedures including osteotomies (four studies, n=38).

Barriers to change
Conservative weight management is recommended as an adjunctive treatment, as it tackles a primary risk factor for obstructive sleep apnoea (on the basis of two randomised trials, combined n=91, and two non-randomised concurrently controlled studies, n=41). Weight loss and other lifestyle modification can be difficult to achieve, however. CPAP also depends on acceptance and adherence by patients; its benefits in mild to moderate obstructive sleep apnoea seem inconclusive,3 10 making surgical "cure" seem more attractive. Furthermore, in Australia, such surgery is mainly done in the private sector, which has different incentive mechanisms from the public system. However, given the lack of clear benefit from surgery and the potential for harm indicated by currently available evidence, guidelines recommend CPAP as first line treatment for obstructive sleep apnoea generally. When CPAP treatment fails, mandibular advancement devices may be considered (with conservative management) as second line treatment (16 randomised trials, n=745).

How should we change our practice?
CPAP remains the recommended first line treatment for obstructive sleep apnoea in adults.Conservative weight management (as a primary risk factor) is recommended as adjunctive treatment. When CPAP treatment fails, mandibular advancement devices may be considered (with conservative management) as second line treatment. Surgery for obstructive sleep apnoea should be done within controlled clinical trials. Patients should be informed about the trial, as well as of the inconsistent results of surgery, the associated pain, the potential side effects, and the potential for relapse.

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